MICRO-INVASIVE TREATMENT OF THE NON … ODONTOLOGY.pdfment technique, addressed to the incipient,...

International Journal of Medical Dentistry 11

AbstractAim: Experimentation of a new, micro-invasive treat-

ment technique, addressed to the incipient, non-cavitatedcarious lesions.

Materials and method: Icon is an innovative productfor the micro-invasive treatment of the carious non-cavi-tated lesions occurring on smooth surfaces, requiring –after a preliminary conditioning of lesion’s surface with15% hydrochloric acid – infiltration of the porous layerobtained with a low-viscosity composite.

Results: 26 non-cavitated carious lesions (22 vestibu-lar and 4 proximal lesions, respectively) were selectedand treated by this technique in the Department ofOdontotherapy, between October 2010-July 2011. Accord-ing to the protocol of the Icon technique, a smooth andglossy surface was obtained through infiltrating the le-sion, similarly to the healthy enamel, the aesthetic aspectbeing re-established.

Conclusions: The Icon technique may be successfullyapplied as a method of micro-invasive treatment of thenon-cavitated carious lesions produced on smooth sur-faces. The studies performed evidenced the efficacy andacceptability of this clinical procedure.

Keywords: non-cavitated carious lesions, smooth dentalsurfaces, infiltration, Icon

INTRODUCTION

The chalky-white spot, as the first visible evi-dence of a caries in the enamel, involves demi-neralization of the enamel under a superficialpseudo-intact layer.

Non-cavitated vestibular caries are frequentlyoccurring in the cervical third of the teeth, caus-ing aesthetic problems mainly in the frontal zoneand difficult restoration. They are caused by aciderosions, by the bacterial plaque, as well as bythe fixed orthodontic devices, in patients withpoor dental hygiene. Even if the lesions may bestopped by prophylactic remineralizing measures,the deep ones, responsible for demineralizationof enamel and of the external third of the dentin,

MICRO-INVASIVE TREATMENT OF THE NON-CAVITATED CARIOUSLESIONS IN THE SMOOTH SURFACES OF TEETH

Luiza Ungureanu1, Albertine Leon2, Anca Nicolae3, Ciobanu Gabriela4

1. Prof. PhD, Dept of Odontology, „Ovidius” University of Constan]a, Faculty of Dental Medicine2. Assist. Prof., Dept of Odontology, „Ovidius” University of Constan]a, Faculty of Dental Medicine3. Assist. Prof., Dept of Odontology, „Ovidius” University of Constan]a, Faculty of Dental Medicine4. Assist. Prof., Dept of Endodontics, „Ovidius” University of Constan]a, Faculty of Dental MedicineCorresponding author – Luiza Ungureanu, e-mail: [email protected]

are remineralized, in most cases, only superfi-cially; the body of the lesion, situated beneath, isstill porous, which explains the persistency ofthe whitish and/or brownish aspect, caused bythe penetration of certain pigments, foodstuffcolouring substances, tobacco, chromogenic bac-teria. Therapeutical solutions, such as: direct ve-neers of composite materials, ceramic veneers,direct composite restorations, are all invasivetechniques, involving removal of dental tissue.

For the non-cavitated enamel caries occurringon the proximal surfaces, the possible preven-tion, remineralization and treatment solutionsare even more difficult to apply.

For all such clinical situations, the ICONtechnique [1] is the most efficient micro-inva-sive alternative, leading to satisfactory aestheticresults. The procedure assumes infiltration ofthe non-cavitated carious lesions of the smoothsurfaces after a preliminary conditioning of thelesion surface with 15% hydrochloric acid, whichincreases enamel porosity. This way, the lesionsof the enamel loose their whitish, chalky aspect,becoming optically quite similar to the healthyenamel, as a result of microporosities’ fillingwith a fluid composite material, which preventsany advance of the lesion and offers a pleasantaesthetic aspect.

The aim of this investigation is to implementthis recent, innovating technique as a solutionfor clinical cases.

MATERIALS AND METHOD

Between Octomber 2010-July 2011, the Icontechnique was applied in the OdontotherapyClinic of the Faculty of Dental Medicine of

Odontology

12 volume 2 • issue 1 January / March 2012 •

Constan]a, to 26 non-cavitated lesions of enamelsmooth surfaces.

The product is available in two variants: IconProximal – for the treatment of incipient proxi-mal caries and Icon Smooth Surface – for smooth,vestibular and oral surfaces.

The Icon technique is efficient in cases ofdemineralization of the enamel layer and of theouter third of the dentin (E1, E2, D1), but not fordeeper lesions in dentin (D2, D3), Fig. 1.

- E1 – lesion present in the outer half of dentin;

- E2 – lesion present in the inner half of dentin;

- D1 – lesion present in the outer third of dentin;

- D2 – lesion present in the middle third of dentin;

- D3 – lesion present in the inner third of dentin.

Fig. 1. Radiographic lesion depth classification ofdental caries according to bite-wing x-rays [1]

Such a procedure of enamel infiltrationcannot be applied to enamel defects caused byfluorosis, hypoplasia, traumas; it is not applieddirectly on either dentin or cement.

Each kit of Icon treatment (proximal, respecti-vely, vestibular) contains: a 0.3 ml screw syringewith demineralizing gel (Icon Etch – 15% hydro-chloric acid); a 0.45 ml screw syringe with

dessicant (Icon Dry – 95-100% ethanol); a 0.45 mlscrew syringe with infiltrant (yellow liquidacrylic resin); 6 proximal (respectively, smoothsurface) tips; 4 interdental wedges (for the IconProximal kit) (Figs. 2-4). [1]

The clinical protocol includes the followingsteps [1]:

1. For the treatment with Icon proximal:• professional teeth brushing; washing with

water and air drying; checking the inter-dental spaces with dental floss; applicationof the rubber dam; slow separation withthe interdental wedge provided in thetreatment kit;

• application of hydrochloric acid on the sur-face of the lesion for 2 minutes; the perfo-rated part of the proximal tip contacts thelesion; the acid gel is released through ro-tation of the screw;

• washing the acid for 30 seconds; air dryingthe tooth;

• application of the Icon-dry dessicant on thelesion for 30 seconds; air drying;

• application of the infiltrant upon the lesionfor 3 minutes, which enters the porousenamel through the perforated part of theproximal tip; the lamp of the dental unitwill be turned off (not to initiate polymeri-zation); removal of the excess material withdental floss; photopolymerization, for 40seconds, from all directions; repeated ap-plication of the infiltrant for one minuteand photopolymerization;

• removal of the dental wedge, of the rubberdam and finishing with abrasive strips.

Fig. 4. Smooth surface tip(for acid gel and infiltrant resin)Fig. 2. Icon treatment kits

Fig. 3. Proximal tip(for acid gel and infiltrant resin)

Luiza Ungureanu, Albertine Leon, Anca Nicolae, Ciobanu Gabriela

pp 11-16


2. For the treatment with Icon smooth surface:• professional teeth brushing; washing with

water and air drying; checking the inter-dental spaces with dental floss; applicationof the rubber dam or of the liquid dam;

• application of hydrochloric acid on the sur-face of the lesion for 2 minutes;

• washing the acid for 30 seconds; tooth dry-ing;

• application of the Icon-dry dessicant on thelesion for 30 seconds; air drying; the chalkyaspect of the lesion will be more pro-nounced; if need be, demineralization is re-sumed for 2 minutes;

• application of the infiltrant on the lesionfor 3 minutes; the lamp of the dental unitwill be turned off; removal of the infiltrantexcess with prefabricated (denser) cottonrolls; photopolymerization for 40 seconds;repeated application of the infiltrant forone minute and photopolymerization;

• removal of the rubber dam and finishing.

RESULTS

Between Octomber 2010 – July 2011, the Icontechnique was applied according to its specific cri-teria, in the Odontotherapy Clinic of the Facultyof Dental Medicine of Constan]a, to 26 non-cavi-tated carious lesions (4 proximal and 22 vestibu-lar lesions of white-spot type), among which spe-cial mention should be made of the following:

Clinical case 1: Patient C.A., 23 year-old – 1.1incipient enamel lesion, type E1 (Figs. 5-10).

Fig. 5. 1.1 Incipient enamel lesion

Fig. 6. Creating the operatory field

Fig. 7. Application of acid gel (Icon Etch –15% hydrochloric acid, 2 min.)

Fig. 8. Application of Icon Dry dessicant(95-100% ethanol, 30 sec.)

Fig. 9. Application of infiltrant resin(liquid acrylic resin, two times)

Fig. 10. Final aspect of carious lesion on 1.1,treated by the Icon technique

MICRO-INVASIVE TREATMENT OF THE NON-CAVITATED CARIOUS LESIONSIN THE SMOOTH SURFACES OF TEETH


Clinical case 2: Patient S.N., 28 year-old, hav-ing non-cavitated, chalky-white erosive lesions,as well as cavitated lesions in the third neck seg-ment of the frontal upper teeth. The non-cavi-tated lesions were treated by the Icon technique(1.3, 1.1 and 2.2), and the cavitated ones, by directcomposite restorations (1.2 and 2.1) (Figs. 11-16).

Fig. 11. Initial aspect of lesions

Fig. 12. Application of retraction cord tobetter expose the lesions

Fig. 13. Application of liquid dam and Icon Etch

Fig. 14. Application of Icon Dry

Fig. 15. Application of infiltrant resin withbrushing motions

Fig. 16. Final clinical aspect

Clinical case 3: Patient P.B., 23 year-old, withwhite-spot type erosion lesions on teeth 1.2, 1.3and 1.4, treated by the Icon technique (Figs. 17-20).

Fig. 17. Erosive dental lesions on teeth 1.2, 1.3, 1.4

Fig. 18. Isolation with liquid dam. Aspect of teethsurfaces after applying Icon Etch and Icon Dry

Fig. 19. Brushing the infiltrant resin onto the lesionsurface to penetrate the porous area


pp 11-16


Fig. 20. Final aspect of the infiltrated lesions,after light polymerization

DISCUSSION

The concept of caries infiltration was de-veloped at Charité University of Berlin, by Prof.Dr. A.M. Kielbassa, and continued at the Uni-versity of Kiel, by Prof. Dr. Christof Dörfer. As aresult of the close cooperation with these twouniversities, Dr. H. Meyer-Lückel, Dr. SebastianParis and DMG manufacturing enterprise putinto practice the results of the research, asproduct Icon (September 2009) [1].

Caries infiltration is a topic of particular in-terest nowadays, which explains the numerousstudies – some of them still in progress – de-voted to it. In this respect, Rocha Gomes Torreset al. [2] observed that product Icon proved to bethe most efficient treatment in masking thechalky aspect of the white-spot type lesions,comparatively with a 0.05% fluoridated solution,while the teeth treated with Icon were more re-sistant to the formation of new chalky-whitelesions. Lohbauer et al. [3] concluded that theinfiltrated vestibular lesions were less affectedby brushing abrasion than the normal enamel.Saviero et al. [4] evidenced that only one-minuteapplication of the infiltration resins at the levelof the proximal 6-year molars permitted penetra-tion of the infiltrant to sufficient depth inside thelesions. Meyer-Lückel and Paris [5] comparedtwo acrylic resins with different penetrabilitycoefficients, which may enter the body of the le-sion through capillarity, if the lesion is dessica-ted with ethanol. Their conclusion was that theresin with a higher penetrability coefficient iscapable of infiltrating the enamel almost comple-tely, when using ethanol as a dessicant. Nobrega

et al. [6] determined the resistance of the lesionstreated with Icon on extracted human, artificiallydemineralized teeth, on the VHN (Micro-Vickershardness test) scale, as compared to fluoridationand the invasive treatment. They demonstratedthat the artificially created carious lesions, trea-ted with Icon, registered favourable results inthe resistance test. Martignon et al. [7] evaluatedradiologically the efficiency of the infiltrationwith resins of the incipient proximal carious le-sions, as against the sealing and the use of dentalfloss, along one to two-year periods of time. Theconclusion was that infiltration of the incipientproximal caries constitutes an efficient methodto reduce the progress of carious lesions. Kim Set al. [8], who evaluated the clinical efficacy inmasking the chalky-white lesions with resin, bythe Icon infiltration technique, derived a goodaesthetic aspect for teeth with post-orthodonticdemineralization. Phark and Duarte [9] com-pared the infiltration efficacy versus post-ortho-dontic fluoridation of the chalky-white lesions,reaching the conclusion that resin infiltrationreduces efficiently the post-orthodontically oc-curring chalky-white lesions, while ensuring goodcolour stability in time. By means of confocallaser scanning microscopy, Paris S, Meyer-LückelH, Müller J et al. [10] were able to appreciate thedepth of resin penetration, as well as the absenceof caries advancement after infiltration.

Restoration, through the Icon technique, of alimited number of clinical cases, allowed thesubsequent observations: a careful selection ofthe clinical cases with porous demineralizationlesions is necessary, to allow infiltration of theliquid resin as deeply as possible inside the le-sions; clinical examination through careful in-spection of the vestibular surfaces, and throughbite-wing radiographs for the proximal dentalsurfaces, is equally necessary to settle correctdiagnosis; for the vestibular surfaces, the tech-nique is very simple and rapid, while, for theproximal ones, the manoeuvre is more complex –however, gradually, the time necessary to ac-complish it may be reduced; even if, undercertain clinical situations, the aesthetic result wasless obvious, sensitivity in the tooth neck zone ofthe treated teeth disappeared.

MICRO-INVASIVE TREATMENT OF THE NON-CAVITATED CARIOUS LESIONSIN THE SMOOTH SURFACES OF TEETH


CONCLUSIONS

• The Icon technique may be applied in prac-tice as a simple, efficient, micro-invasivemethod in treating non-cavitated lesions inthe smooth surfaces of teeth, securing bothinfiltration inside the lesion and stoppingdemineralization, while restoring the aes-thetic aspect, a compulsory requirementmainly in case of lesions occurring on thevestibular surfaces of teeth.

• Despite its recent application (2009), nu-merous studies have already ascertainedthe efficiency of this technique, recom-mending its extended application; never-theless, further clinical and paraclinicalstudies – performed on an as large numberof treatments as possible – as well as theirmonitorization in time, are still necessary.

• Clinical experience evidenced that the pa-tients accepted a conservative method,causing practically no pain, yet providingimmediate satisfaction.

References1. www.drilling-no-thanks.com2. Rocha Gomes Torres C, Marcondes Sarmento Torres

L, Silva Gomes I, Simoes de Oliveira R, BuhlerBorges A. Effect of caries infiltration technique andfluoride therapy on the color masking of white spot

lesions, www.dmg-dental.com/downloads/scientific-documents

3. Lohbauer U, Ebert J, Schubert EW, Petschelt A.In-vitro-Rezistenz von kunststoff-infiltrierter Initial-karies (White Spots) gegenuber Zahnburstabrasion.2009, www.dmg-dental.com/downloads/scientific-documents

4. Saviero V, Paris S, Séllos M, Meyer-Lückel H. Effectsof application time on infiltrant caries penetration exvivo. J Dent Res 2010; 89 (Spec Iss A): 2521.

5. Meyer-Lückel H, Paris S. Infiltration of natural lesionswith experimental resins differing in penetration coef-ficients and ethanol addition. Caries Res 2010;44: 408-414.

6. Nobrega D, Perry R, Kaminsky E, Finkelman M,Kugel G. Unique treatment of early caries and whitespot lesions. J Dent Res 2010; 89 (Spec Iss A): 2522.

7. Martignon S, Ekstrand KR, Lara JS, Gomez J, CortesA. 2-Year Radiographic Results of Proximal CariesLesions’ Infiltration, Sealing and Flossing Instruc-tions, www.dmg-dental.com/downloads/scien-tific-documents

8. Kim S, Shin JH, Kim EY, Lee SY, Yoo SG. The evalua-tion of resin infiltration for masking labial enamelwhite spot lesions. Caries Res 2010; 44: 171-248,Abs. 47.

9. Phark JH, Duarte S. Clinical performance and colorstability of infiltrated smooth surface lesions.www.dmg-dental.com/downloads/scientific-documents

10. Paris S, Meyer-Lückel H, Müller J, et al. Progressionof sealed initial bovine enamel lesions under demine-ralizing conditions in vitro. Caries Res. 2006;40(2):124-129.


pp 11-16

MICRO-INVASIVE TREATMENT OF THE NON … ODONTOLOGY.pdfment technique, addressed to the incipient,...

Documents

Transcript of MICRO-INVASIVE TREATMENT OF THE NON … ODONTOLOGY.pdfment technique, addressed to the incipient,...